Basic Information
| Provider Information | |||||||||
| NPI: | 1952319378 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURGICAL CENTERS OF GA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3556 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312102509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784759250 | ||||||||
| FaxNumber: | 4784759315 | ||||||||
| Practice Location | |||||||||
| Address1: | 3556 RIVERSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312102509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784759250 | ||||||||
| FaxNumber: | 4784759315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | VITO | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4784759250 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 011177 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 436300 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER |